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GRAS HDI GUtTER ANCHORAGE AREA BOROWiH
HEALTH DEPARTMENT
327 EkiLE ST. ANCHORAGE, ALASKA 99501 2»-2511
• INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
,ME G
OG!'
MAILING
SEPTIC TANK:'
NUMBER OF /
DISTANCE FROM WELL MATERIAL ��� COMPARTMENTS
-✓/3L11%�'C.� %9i�� �,i LIQUID A�
LIQUID CAPACITY n C�C2 GALLONS. INSIDE LENGTH INSIDE WIDTH DEPTH
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS / OUTSIDE DIAMETER OR WIDTH. LENGTH , DEPTH
LINING MATERIAL C/Lyt�C �t . DISTANCE FROM WELL- �O , BUILDING FOUNDATION�� t
NEAREST LOT LINE 20 / TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)✓ �' SO. FT.
TILE DRAIN FIELD:
TOTAL LENGTH
DISTANCE FROM W , FOUNDATION , NEAREST LOT LINE , OF LINES ,
NUMBER LINES DISTANCE BETWEEN LIN T NCH WIDTH IN. TOTAL EFFECTIVE
AB RPTION AREA SO. LENGTH OF EACH LINE
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE
DISTANCE FROM I 1-d WATER �y/Q
WELL'
TYPE f���L�DEPTH BUILDING FOUNDATION. le z SAMPLE NEAREST
NEAREST SEPTIC _G, SEEPAGE L ' .1 v OTHER `'
LOT LINE . SEWER LINE ,TANK Zt, SYSTEM. '_CESSPOOL_.SOURCES_
DIAGRAM OF SYSTEM
DISTANCES: 4 ;
o«r?y/,cis I I r :<<
C/
DATE �'���'{ ,APPROVED HEAtIH AUIHOAHY ✓
GREATEr stNCHORAGE AREA
IIEALTII DEPARTNIENT
327 Eagle St. Anchorage, Alaska 99501
(�JROUGH
279-2511
Case No. lz�
SEWAGE DISPOSAL SYSTEPA- APPLICATION & PERMIT
NAME OF APPLICANT ' AILING ADDRESS PHONE NO.,
t LOCATION OF INSTALLATION
RESIDENCE ADDRESS _ IO
LEGAL DESCRIPTIONo'-V M�
APPLICATION TO INSTALL: SEPTIC TANK ��{. S"�E
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH
PERCOLATION TEST RESULTS
EPAGE PIT "D
TO BE INSTALLED
ANTICIPATED DATE OF COMPLETION 24)
RfELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO 4ERVE AS �A!—�4,��ls PERMIT TO INSTALL A
AS DESCRIBED BELOW. SIZE OF UNIT TO E SERVED
SEPTIC TANK SIZE 1000 TYPE A SEEPAGE AREA11-it TYPE
DIAGRAM OF SYSTEM
DISTANCES:
f} — .6 — goy% 4 -
HEALTH AUTHORITY
OR
LICENSED DESIGNER
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the
above described system is in accordance with said code.
DATE � r �T ` 2 D APPLICANTS SIGNATURE ✓